Homerton and Whittington, two London trusts working as pilot sites for WTD 2009, have revealed their approaches for achieving compliance.
Homerton University Hospital NHS Foundation Trust’s project to separate emergency and elective care is now in place, however the Whittington Hospital NHS Trust was unable to complete their planned changes devised with the Royal Free Hospital. Their proposals investigated the benefits of new and extended roles in surgery and anaesthesia, but were halted because of internal and external difficulties.
Emergency and elective care project
Homerton University Hospital NHS Foundation Trust separated emergency from elective care by creating highly trained, multiprofessional teams to care for emergency medical, surgical and orthopaedic admissions on two redesignated acute care wards.
The increase in dedicated beds was balanced by a corresponding reduction in general beds in other departments, as the improved immediate care on admission reduced the demand for them.
WTD compliance has been achieved by separating the rotas of junior doctors to allow time dedicated exclusively to the care of emergency admissions and time devoted to the development of skills in base specialties. This split varies according to the training needs of doctors and their specialties.
The project was led by medical director Dr John Coakley, a consultant in intensive care medicine, together with chief operating officer Tracey Fletcher.
Dr Coakley said, “This kind of project needs good management, someone who can say the organisation will make changes and keep to a deadline. In our case we did not delegate those responsibilities to middle management.”
The pilot had the engagement and support of the chief executive and executive directors and they ensured that members of their respective teams were available and actively involved with it throughout its duration.
He said both the clinical director and clinical tutor were committed to the pilot and the team built ‘a considerable consensus’ around the plans. “We had strong executive leadership and stakeholder involvement in the build up. We sought stakeholder feedback quickly and acted on it.”
Dr Coakley emphasises that it was important to acknowledge at the outset that not every aspect of their plans would run smoothly immediately, he said: “Because we understand that whenever you make changes, some aspects improve and some may get worse, we wanted to set up a system where any problems, dangers or lowering of quality would be identified very quickly and more importantly, put right.
“That needed a range of sources for advice, support and change and a team of people from the project manager to the clinical director who could act swiftly on issues brought to our attention.”
Within a short time, Homerton did make changes to its original plans to have one 56 bed acute ward, created from two smaller existing wards, for emergency admissions.
“It soon became clear that this was too big, so we have changed to one 34 bed ward and 22 acute beds in another,” he said. “Similarly, it became clear that the new junior doctors’ rotas were unnecessarily complicated so we made changes as quickly as it was feasible.”
Balancing the service and training needs is also vital in any planned changes and it is important not to concentrate on one at the expense of the other, he said: “We have expanded the consultants’ working day, they are now in the hospital for 12 hours during the day to maintain the percentage of time junior staff are supervised.
“We have maintained the junior staff training time while reducing their hours, but it’s too early to say whether the quality of training is better or worse or just different.”
Dr Coakley also says trusts must avoid the danger of assuming ‘the finance will look after itself’, and plans must always be made in the light of the trust’s national priorities and targets.
Chief operating officer Tracey Fletcher says one of the difficult aspects of the pilot was the timing, which coincided with the introduction of Modernising Medical Careers (MMC), she said: “We had to separate the issues of WTD compliance and MMC.”
Another challenge was to assess the impact of the changes on elective care and find solutions for dealing with it. “If we were going to cut or lose hours and change the management of non elective patients, we had to look at how that may affect the elective side,” she said, admitting there has been some pressure on the management of the host specialty wards.
Although the changes have been implemented, she says the picture is by no means complete. “It’s only after implementation that you can continue to rebuild further down the line.”
Because of the interest shown in the Homerton pilot by other trusts, the hospital is considering organising study days to pass on their experience and learning.
Cross over site cover out of hours
The Whittington Hospital aimed to identify solutions that could be used in other trusts within London and nationally by exploring the feasibility of cross over site cover out of hours.
The final report of its WTD pilot states the project encountered both internal and external difficulties, it states: “There are two types of learning for the trust from this pilot, from the actual running of the project and trying to deliver its aims.”
If the trust was asked that, with hindsight, would it have approached the project differently, the answer would be ‘yes’.
The pilot project encountered two internal difficulties, the first of which was when its project manager was seconded to a transformation team, established when the trust faced potentially serious financial difficulties in the autumn of 2006. Their priority became immediate cost improvement schemes, rather than looking ahead to the impact of the 2009 WTD.
Then, the Whittington had applied to become a foundation trust (FT), which changed the emphasis for resources.
The report also identifies three main external issues. The first stated: “the current arrangements for commissioning and funding NHS services, designed to create competition between provider organisations, impacts on the approach taken by providers to negotiate changes which may potentially destabilise elective surgery and related emergency services.”
The second was that the two hospitals’ applications to become FTs did not necessarily engender collaborative behaviour between trusts, unless it could be seen clearly by both as being in their interests.
The final issue involved the implications of the Darzi report which raised some uncertainties around future arrangement of services.
Celia Ingham-Clark, medical director of the Whittington Hospital trust, says:
“We have still got to solve the problem of the WTD. People cannot close their eyes to the issue and hope it will go away, it won’t.”
She emphasises the importance of project management in any pilot or planned changes. “It needs a dedicated project manager who has the vision to see it through as well as handling the practicalities of ensuring meetings actually happen. Everybody else has a day job and with so many competing pressures, the most immediate ones tend to take precedence. This is about trying to achieve something for the future.”
The original plan included two options for general surgery to combine the consultants’ on call rotas. They were either to operate alternate nights on call between the two hospitals with the ‘hot’ hospital providing the on call consultant, available to give advice to the ‘cold’ hospital, or for one of the two hospitals to undertake all the out of hours emergency surgery.
In that case general surgery consultants from both hospitals would contribute to a combined on call rota to support the service.
But the trust encountered difficulties. Celia Ingham-Clark said that although London Ambulance Service was ‘sympathetic’ to their plans, the systems were not in place to make it possible.
“Although similar schemes have been running elsewhere in the UK, the situation in London is more complex and includes ambulance crews coming in from surrounding counties,” she said. “There would need to be in place more detailed supervisory systems, the last thing anyone wants is for a patient to be taken to the wrong hospital.”
The final report states that if out of hours emergency surgery was to be focused on one of the two sites, the other might be perceived to be less able to deliver emergency care at other times. It states: “Each site felt it would be vulnerable without a middle grade surgeon on site 24/7 since surgical emergencies can commonly arise in medical in-patients or in post operative elective surgical patients.”
The report also acknowledged that in “The current competitive environment of the health service” no trust can afford to show any potential weakness that might threaten its commercial viability.
www.healthcareworkforce.nhs.uk/pilotprojects
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